I spent several days this week performing an assessment of a client’s EHR support team. The IT director had been pressing leadership for more employees. The CIO, however, suspected that perhaps there were other issues on the team keeping people from being maximally productive. I had been tasked to determine not only whether there are process issues, but whether the team has the right skill sets to be effective.

You may be asking why a physician or CMIO is doing this kind of work. Even though this type of work can be done by non-physician consultants, many of the organizations I work with have found that the recommendations carry more weight when they come from a clinical informaticist.

Just observing in the office, I found the usual distractions and interruptions – instant messenger, email notifiers, and text messages which kept people from focusing on their work. Additionally, the support staff wasn’t particularly differentiated as far as which types of issues they handled. Working with somewhat of a call center mentality, staffers were expected to handle every call that came through in a round-robin fashion, regardless of the nature of the issue. Staffers were positioned to handle whatever was on the other end of the phone, even though the callers might have neurosurgical problems and the person answering the phone might be a rheumatologist.

The support team had varying levels of experience – some were clinical, some were technical, and some actually had zero healthcare IT experience and minimal training yet were expected to handle calls successfully. Part of my assessment includes individual staff interviews, during which I determined that one staffer in question had never even been to formal training on the application he was expected to support. Worse, he wasn’t a new employee, but had been there for nearly six months, and his manager had continually promised she would get him scheduled for training but never delivered.

That in itself was a red flag. It’s hard to on-board employees when you don’t have a formal training program. The best organizations I have worked with expect new hires to complete specified training and demonstrate proficiency within the first 90 days. At some, this may also include achieving certification from the vendors of the applications they are supporting, if they are not already certified. Usually those requirements are baked-in as conditions of employment, making it easier to break with someone who can’t meet expectations.

The individual interviews also uncovered that some team members had particular expertise that was going to waste considering how they were being utilized. One was a lab expert, another was a nurse, and yet another had extensive process improvement training from a previous position. Given their round-robin deployment on support tickets, their skills were going unused. Several of their responses indicated boredom and frustration.

My interview of the manager was particularly enlightening. She stopped the interview multiple times to deal with text messages, phone calls, and even people walking by the office. Observing her outside the interview, I can only describe her work habits as firefighting. Everything was a crisis requiring immediate attack.

I also interviewed a director and a vice president, neither of whom seemed particularly knowledgeable about the work going on below them. They seemed fairly content to manage from above without accountability for their teams’ performance. One flatly stated that, “Getting results is why I have managers. That’s their job, not mine” even though he acknowledged that his managers weren’t terribly effective in actually achieving the desired goals. The VP admitted he had no experience with clinical systems or working with physician groups and that he had just been given this department when the last VP left.

It was clear that culture issues were at play as well as general inefficiencies, and I included a discussion of that problem in my formal report. I was looking for additional documentation about workplace distractions and came across several recent pieces about email as one of the roots of all evil.

Despite their best intentions, people struggle with email management. This is particularly acute in organizations like my client’s, who don’t have clear policies about email use. When I’m engaged to provide guidance, I always recommend policies which include expectations for response (if you need a response in less than three business days, you need to use phone or in-person communication) as well as a specification on which types of issues belong in email and which don’t.

Interesting in some of the studies was the fact that employees using email were less likely to achieve deep work states. Over the last year, I’ve started seeing more organizations where employees never achieve deep work states. Sometimes they’re constantly dealing with customer “fires,” but more often, I’m seeing employees who are put in that position by a lack of leadership and strategic planning. In workplaces with these cultures, I often see evidence of people working from home or from their phones. When asked about these behaviors, workers often cite “the need to keep up” or the fact that they can’t get anything done at work. Both of these are just symptoms of a larger problem.

In other situations, workers may not understand how the tasks they are performing fit into larger initiatives, which can create frustration. One client I worked with in the fall was running parallel initiatives out of two teams without any coordination of efforts. Leadership didn’t account for the fact that employees have friendships across teams, and when they learned of the parallel efforts, their perception was that their projects were competing rather than complementary. This lead to a spiral of frustration as workers were suspicious that they were being set against each other or that a “losing” team might end up being downsized.

In one organization I recently visited, people were constantly told about the organization’s key objectives and vision, but there has been little to no communication about how they’re actually going to go about achieving those objectives. That type of work environment quickly leads to frustration and then to apathy. I also had concerns about workplace violence, as the marketing department had the corporate focus words imprinted on stones for employees to have as focal points on their desks. I’m betting more than a few of them get thrown from time to time.

These higher-level dysfunctional behaviors were present at my client, in addition to the micro-level dysfunction that I identified looking at their individual work habits. What the client felt was going to be a straightforward analysis of their EHR support team revealed not only a poor staffing plan and misuse of some fairly expensive human capital, but also a lack of strategic planning. There were also some other red flags in dealing with this client. I knew that my findings weren’t going to go over well because they didn’t fully support management’s original theory that the team was overwhelmed or just wasn’t working hard enough.

Fortunately, I had scheduled an onsite presentation of my findings so that we could discuss them rather than just sending them a report after the fact and having a call to review. Although some members of the leadership team seemed genuinely shocked (or at least were very good at making it look that way) the majority of them didn’t seem terribly surprised. Several of them (including the director and the VP) were skeptical of the findings and my recommendations, and based on their responses, I don’t think they’re at a point where they’re ready to make changes.

One of them actually accused me of “muck-raking,” which is a term I haven’t heard since the last time I took an American History class. Another (who apparently missed the memo on why I was there in the first place) said I was just “coming up with make-work tasks to justify my existence.” Those are pretty powerful words to say to someone who was specifically hired to complete a well-defined project, not to mention to someone who was specifically hired by your boss to figure out why your department is a disaster.

I didn’t find their responses surprising at all since they were obviously trying to defend their turf and protect their own necks. We’ll have to see what the CIO decides to do with the findings. Based on the personalities involved and their obvious resistance to change, I’m not too thrilled about the possibility of a follow-up engagement should they request one.

Regardless of where they decide to go from here, I left them with quite a few concrete recommendations for the team in question as well as for their leadership team. It’s sad to say, but clients like this are becoming the norm for me. I’m eager to do work for an organization that has leadership, vision, and focus but just needs a kick in the pants to get it done rather than one that seems oddly happy in their dysfunction.

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Currently there are "4 comments" on this Article:

You get what you pay for. I am shocked at how little VPs and Directors at even large health systems are paid. Those same health systems have no qualms paying boatloads of money to consulting and vendor organizations. While the news article about Epic youngins having to put their starbucks coffees into generic cups may or may not be true, they certainly are asked not to discuss where they went to dinner (since it’s more likely to be places where the customer staff may not be able to afford to eat).

I don’t know where you get your information Glad, but that’s nonsense. Everything I ever saw out of Epic included a list of reasonably priced recommendations for dining and a request to be good stewards of client funds. That includes the corporate prohibition on alcohol. Nice of you all to try to brand Epic as being so irresponsible though. Heaven forbid anyone have a coffee. Where’s the hue and cry about the more than a billion dollars of corporate welfare the fine people of Kansas City gave Cerner? http://www.histalkpractice.com/2016/03/27/population-health-management-weekly-wrap-up-32716/

This was an interesting and enlightening read, and I’m really glad you took the time to relay the events in such detail, with so many examples. “It’s sad to say, but clients like this are becoming the norm for me…. happy in their dysfunction.” I’m curious as to why this type of organizational dysfunction is increasingly becoming the norm in healthcare environments. Re: staff not being trained, at times there seems to be a belief that “user-friendly” means “just press a button – nothing further required” – in other words, an underestimation of the complexity of EHR applications and the skills and training required use them effectively. Great to see your acknowledgement that if they’re not ready to make changes, there’s no magical approach or technique that can change that. It really is up to senior management to establish and shape a healthy environment and culture – this piece was a great reminder of that.

Your role as a consultant can be reduced to the following, rather cynical outcomes.

Either your changes are accepted, successful, a big hit. Management takes the credit for being ‘visionary’ having hired you and seeing the changes through to completion.

Or, your changes are rejected at any point before, during or after implementation. Management takes the credit for having identified ‘dangerous changes’ from a ‘rogue consultant’ and saving the company.

Consultants are the universal safety valve for introducing change into an organization. Management can claim victory no matter what happens. I’m firmly convinced that existing management often knows what to do but brings consultants in anyway in case a sacrificial goat is needed.

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